MEDICAL RELEASE AND PERMISSIONS FORM

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Elevate Youth Group - First Presbyterian Church of Upland
Calendar Year 2022

Student's First Name *

Student's Last Name *

Date of Birth *

YYYY

Address *

T-Shirt size

XXL

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Health Insurance Company *

Health Insurance Policy/Group Number *

List important health information (allergies, medications, or conditions) or state NONE if none apply. *Also, indicate if your child cannot swim. *

Print your first and last name in the box as an acknowledgment of the following statement: I desire for my son/daughter/ward to participate in First Presbyterian Church of Upland (FPCU) events during 2022 and give my permission for him/her to do so. I further authorize FPCU and its volunteers, staff, and agents to provide first aid to my son/daughter in accord with their judgment, and this treatment may include the administration of over-the-counter (non-prescription) medications to my child and other medications which my child has been prescribed. In the event my son/daughter, in the opinion of First Presbyterian Church or its volunteers, staff, or agents, needs medical care beyond first aid and over-the-counter (non-prescription) medications, I give my consent and permission for such medical care to be obtained on behalf of my child and further give consent to any treatment recommended by the medical personnel consulted. I further understand that photos and videos of FPCU events will be taken and authorize the taking and publication of photographs and videos of my child via the internet or other medium. I understand that FPCU events may include travel by church vehicles and private vehicles, and such vehicles will be driven by church staff and adult volunteers. I further understand that FPCU events may include hiking, tree climbing, rock climbing, zip line, bicycle riding, bowling, swimming and water activities, and/or adventure centers as well as other activities. I freely and voluntarily assume the risk of personal injury to my child/ward (or myself if 18), even if the result of the negligence of FPCU or its volunteers, staff, or agents, and further hold harmless FPCU and its volunteers, staff, and agents and release any legal claims of any kind involving any and all injury, disability, death, or loss or damage to person (including myself, and my child/ward) or property, whether caused by the negligence of the releasees or otherwise. I UNDERSTAND I AM GIVING UP IMPORTANT LEGAL RIGHTS BY SIGNING THIS DOCUMENT *

Emergency Contact Name *

Emergency Contact Phone Number *

Today's Date *

YYYY

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